Intradural view of the spinal cord and dura after three-column osteotomy: illustrative case.

Zirun Zhao,Praveen V Mummaneni,Dean Chou,Saman Shabani,Nitin Agarwal

doi:10.3171/case21497

Abstract

BACKGROUNDA three-column osteotomy results in dural buckling, which may appear concerning upon intraoperative visualization because it may appear that the neural elements may also be buckled. The authors presented an intraoperative view after intentional durotomy of the neural elements and the relaxed state of the dura after three-column osteotomy.OBSERVATIONSA 52-year-old woman with adult tethered cord syndrome and previous untethering presented with worsening leg pain and stiffness, urinary incontinence, and unbalanced gait. Magnetic resonance imaging demonstrated an arachnoid web at T6 and spinal cord tethering. Spinal column shortening via three-column osteotomy was performed with concomitant intradural excision of the arachnoid web. Dural buckling was observed intraoperatively after spinal column shortening. After the durotomy, the spinal cord was visualized without kinking or buckling.LESSONSDural buckling after spinal column shortening of 15 mm via three-column osteotomy at T6 did not result in concomitant buckling of the underlying neural elements.

Highlights

A three-column osteotomy results in dural buckling, which may appear concerning upon intraoperative visualization because it may appear that the neural elements may be buckled
Observations Revision Tethered cord syndrome (TCS) surgery can be morbid at the index site of tethering because dissecting the spinal cord off the dura can be morbid, risking iatrogenic neurological worsening.[16,17]
Revision untethering carries risks of cerebrospinal fluid (CSF) leak, pseudomeningocele, infection, and wound complications.[6,18]. In light of these issues, spinal column shortening is an alternative because there is no direct revision detethering, decreasing the likelihood of neurological injury

Summary

BACKGROUND

A three-column osteotomy results in dural buckling, which may appear concerning upon intraoperative visualization because it may appear that the neural elements may be buckled. LESSONS Dural buckling after spinal column shortening of 15 mm via three-column osteotomy at T6 did not result in concomitant buckling of the underlying neural elements. First reported by Kokubun et al in 1995, spinal column shortening has been demonstrated to be a safe and effective treatment for TCS.[9,10,11,12,13,14] This approach indirectly relieves the longitudinal tension of tethered neural elements. The dural buckling that can ensue after spinal column shortening can appear concerning intraoperatively, and it is unclear if the underlying neural elements are kinked. Previous reports have not shown an intradural view of the spinal cord after shortening.[9,11,13,15] Because of the need to concomitantly excise an arachnoid web in this case, the dura was opened. An intraoperative view of the spinal cord and open dura is presented

Illustrative Case

Findings

Discussion